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Essential Health Benefits. Mim Dixon USET Training May 22, 2012. Affordable Care Act (ACA). Requires all new plans to have EHB QHPs and plans outside Exchanges Exempt from EHB requirement: Self-insured group health plans Large market health plans Grandfathered group market plans
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Essential Health Benefits Mim Dixon USET Training May 22, 2012
Affordable Care Act (ACA) • Requires all new plans to have EHB • QHPs and plans outside Exchanges • Exempt from EHB requirement: • Self-insured group health plans • Large market health plans • Grandfathered group market plans • 10 categories of EHB in ACA • Secretary of HHS decides what services are included in each category
Essential Health Benefits (EHB) • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services • Laboratory services • Preventive and wellness services, chronic disease management • Pediatric, including oral and vision
Why is EHB important for I/T/U? These are the covered services that you can be paid to deliver to people enrolled in health insurance plans.
Benchmark Plans for EHB for Exchanges • HHS Secretary defers to States • States must choose benchmark from 3 largest in state in any of these categories: • Small group plan with largest enrollment • State employee benefit plan • Federal Employee Health Benefit Plan (FEHBP) • Commercial non-Medicaid HMO
Default Benchmark Plan • Largest small group market product in the State’s small group market. • Federally-operated Exchanges will use default.
Limitations on Benefits • Benchmark plans may limit number of visits or amount of service. • Exchange may substitute benefit categories, keeping actuarial value. • Must comply with Mental Health Parity and Addiction Equity Act (MHPAEA) • Pediatric oral and vision services may be offered by separate plans. • Orthodontics excluded, except medically necessary
Limit on Limits • Plans may have limits on scope and duration of services. • Plans may not have annual or lifetime dollar limits on EHB. • Preventive services (under 2713 of PHS Act) must be part of EHB.
Medicaid Expansion • State may use Exchange benchmark plan for EHB for • Medicaid Expansion population • Traditional Medicaid under Section 1937 • Basic Health Plan
Tribal Consultation on EHB • Seek to have no limits number of visits, especially behavioral health. • Keep Medicaid plan EHB more generous than Exchange plans. • QHPs should include pediatric oral and vision services to make enrollment/sponsorship easier.